OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES FIRE CHARTER APPLICATION

Transcription

1 OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES FIRE CHARTER APPLICATION RETURN COMPLETE APPLICATION TO: OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES 1970 WEST BROAD STREET P.O. BOX COLUMBUS, OHIO

2 The Fire Charter Application Each institution applying for a fire charter to provide firefighter, fire safety inspector, and instructor training is required to complete this application. The criteria used in the evaluation is based upon the Ohio Revised Code (R.C.) Section , and rules promulgated by the Executive Director, with the advice and counsel of the Firefighter and Fire Safety Inspector Training Committee, in Ohio Administrative Code (O.A.C.) Chapter Additionally, each institution will have to specify which classification levels, volunteer firefighter, firefighter I, firefighter II, fire safety inspector, fire instructor, and / or fire safety inspector instructor, that the institution wishes to teach. The ultimate goal of a fire charter application process is to help a training program attain its own goal providing a quality educational experience for students to become competent fire service providers. The effectiveness of a fire charter application process depends upon the fire training program's honest, self-reflective analysis of its strengths and challenges based upon the approved standards. The answers should be prepared in clear and concise language and respond to each of the questions asked. Programs that intend to offer fire service education at the high school level must include relevant documentation as part of their application. Organization Prior to Preparation of the Application The development of an application can take from three to six months; therefore a realistic and detailed timetable should be created. Although the exact organizational plan will vary from institution to institution, the following suggestions may be helpful: 1. Select an appropriate member of the staff to direct the preparation of the application. 2. Involve members of the faculty, administration, and advisory committee in application discussions. 3. Adopt a reasonable time schedule and adhere to the schedule. Completing the Fire Charter Application The application is divided into six sections. Each section requires the applicant to determine if the program is in compliance with the specific requirements found in R.C. and O.A.C. It is the responsibility of the applicant to submit a complete and accurate application consistent with R.C. and O.A.C. requirements. 1. A review of the following R.C. section and O.A.C. chapters will provide assistance in completing the application. a. R.C Fire Service Training Programs b. O.A.C Fire Chartering c. O.A.C Fire Certification d. O.A.C s e. O.A.C Professional Standards f. O.A.C Disciplinary Actions 2. It is the responsibility of the applicant to submit a complete and accurate application. Should you have any questions while completing this application, please contact the Fire Education Coordinator at the Division of EMS at (800) a. Complete all sections of the application. An incomplete application will not be processed or considered. An incomplete application will be returned to the applicant. b. Review the completed application to ensure it accurately represents the proposed program. c. Review and sign the Application for Fire Charter Check List. d. Make a copy of the application for the Fire Charter training program files. 3. Upon receipt and review of the application a representative of the Division of EMS will contact the applicant to schedule an on-site review of the facilities, equipment, and required documentation. 4. Once a complete review of the application and an on-site review are conducted, the Executive Director shall grant or deny the Fire Charter Application. EMS /15 [ ] Page 2 of 25

3 Appendix A FIRE CHARTER APPLICATION CHECKLIST The following documents must be included as part of a complete application submission: Authorizing official statement of support for the fire charter Fire charter training program organizational chart Advisory Committee membership list Demonstration of adequate financial resources to operate the fire charter Current and signed affiliation agreements for equipment, supplies, facilities, and apparatus List of current approved fire training offsite locations Appendix B List of Ohio certified s, Assistant s, and Fire Safety Inspector Instructors utilized by the charter, including certification numbers and expiration dates Copy of all evaluation forms from instructor supervisors / peers List of name(s) of the charter proctor(s) for the state certification examination List of instructors utilized as skill coordinators and evaluators for the practical skills testing. Include the date of completion of the Practical Skills Evaluator Training Course in addition to their certification numbers, certification levels, area(s) of expertise, and expiration dates List of instructors utilized in any live fire training evolutions. Include the date of completion of the Live Fire Training Operations Course (For new instructors after April 7, 2014) Appendix C Student admission application Copy of proposed syllabus for each fire training level to be offered Curriculum hours for each classification level to be offered Course schedule and lesson plans for each fire training level to be offered Fire testing and practical skills forms and documentation Copy of students course evaluation form Online or distance learning documentation Appendix D Written policies and procedures in compliance with O.A.C Written policies and procedures for conducting live fire training (includes live fire burn plan and diagram of burn facilities) Written policies and procedures for the administration of the state written certification and practical skills testing Policies and procedures for management of student and course records Copy of signed Written Testing Agreement This application has been: Reviewed to assure all questions were answered Reviewed and signed by the Authorizing Official and Program Director Duplicated for the training program file PROGRAM DIRECTOR (Printed) PROGRAM DIRECTOR SIGNATURE X DATE Return Application to: Ohio Department of Public Safety Division of Emergency Medical Services 1970 West Broad Street P.O. Box Columbus, Ohio EMS /15 [ ] Page 3 of 25

4 SECTION I: FIRE CHARTER APPLICATION (Please type or print legibly. Mark all that Apply) Initial Fire Charter Additional Classification Charter Renewal Charter Reinstatement Volunteer FF I FF II FSI FSI Instructor Live Volunteer FF I FF II FSI FSI Instructor Live Volunteer FF I FF II FSI FSI Instructor Live Volunteer FF I FF II FSI FSI Instructor Live Will this fire charter be conducting a fire training program for a high school / secondary school? Yes No Is this fire charter also an EMS Accredited training site? Yes No SECTION II: GENERAL PROGRAM CONTACT INFORMATION (Please type or print legibly) PROGRAM (NOTE: Name of organization must match the name on the certificate) CHARTER NUMBER CITY STATE ZIP COUNTY PHYSICAL ADDRESS TELEPHONE NUMBER FAX NUMBER PROGRAM ADDRESS PROGRAM WEB ORGANIZATION TYPE 4-Year University / College 2-year Community College JVS / Career Center Fire Department Private Institution Other Is charter under any discipline, to include suspension or revocation; or under limitation by the Executive Director? Yes No If reinstatement was charter and / or classification level(s) in good standing when the charter or classification expired or was voluntarily surrendered? Yes No EMS /15 [ ] Page 4 of 25

5 SECTION lii: ADMINISTRATION AUTHORIZING OFFICIAL INFORMATION * This person has signature authority for the organization and either owns, or maintains responsibility, on behalf of the organization for the facilities, equipment, instructors, managers, and other employees of the chartered program. O.A.C (C) TITLE CITY STATE ZIP COUNTY TELEPHONE NUMBER FAX NUMBER ADDRESS PROGRAM DIRECTOR INFORMATION TITLE CITY STATE ZIP COUNTY TELEPHONE NUMBER FAX NUMBER CELL PHONE NUMBER ADDRESS 1. Describe the roles and responsibilities of the program director to include: Job description; Ongoing review and evaluation of the program content, instructors, and students performance; Assignment of faculty responsibilities and scheduling of program courses; Assuring the adequacy of all program training materials and; Assuring the integrity and security of the written examination and practical testing process. Submit an organizational chart under Appendix A. 2. By what methods will the program director assure courses are developed under the direction of those that specialize in fire service training? 3. Indicate the method by which the program director will attest to the competence of each training program graduate. Check all that apply. Course written quizzes / examinations Course practical skills assessments Other 4. Which type of records will you utilize? Paper Electronic (Check both if applicable) EMS /15 [ ] Page 5 of 25

6 SECTION IV: FINANCIAL RESOURCES 5. Are there adequate financial resources for the satisfactory delivery of the fire training program? Yes No Comment(s): Submit documentation of adequate financial resources to operate a fire training program under Appendix A. 6. How will the training program be funded? Tuition Only Tuition and ADM subsidy Tuition and program subsidy Other 7. What will be the total cost to a student including tuition, fees, books, uniform, and personal equipment? Course Offering(s) Total Cost to Student Volunteer $ Firefighter I Transition $ Firefighter I $ Firefighter II Transition $ Firefighter I and II $ Fire Safety Inspector $ $ Fire Safety Inspector Instructor $ Live Fire Training Operations Level Instructor $ 8. Demonstrate that the program has adequate equipment and supply budget. Documentation must include primary sources of income and expenses. SECTION V: FACULTY 9. Describe the methods used to select your faculty and assign staff. 10. Describe the record management system used to ensure that the training program instructors will be appropriately certified to teach at or below their level of Ohio fire certification. Submit list of Fire instructors, Assistant Fire Instructors, Live s, and Fire Safety Inspector Instructors utilized by the charter, including certification numbers and expiration dates under Appendix B. 11. Explain your policy on ensuring your instructors will be regularly evaluated. Submit supervisor and peer evaluation forms under Appendix B. 12. Describe any continuing education opportunities available to the training program s instructors. 13. Describe what documentation is to be maintained in the instructor files. Documentation must be maintained for the previous and current charter cycles and available at the time of on-site review. EMS /15 [ ] Page 6 of 25

7 SECTION VI: FACILITIES AND RESOURCES 14. Are you providing classroom facilities and equipment which are safe, sanitary, and conducive to learning? Yes No Comment(s): 15. Are the classroom and laboratory facilities adequate to support the curriculum objectives established by the Executive Director? Yes No Comment(s): 16. Are the classroom and laboratory facilities adequate to accommodate the expected enrollment? Yes No Comment(s): 17. Is there an established office area available for use by the program faculty? Yes No Comment(s): 18. Are any of the facilities shared with other programs? Yes No If yes, what facilities are shared? 19. Has the program director visited all of the facilities, to include offsite locations, which will be utilized, to ensure that the equipment, supplies, and apparatus meet the performance objectives for the current NFPA 1001, Standard for Fire Fighter Professional Qualifications? Yes No If yes, copies of the current, signed affiliation agreements as well as a list of all offsite locations must be included in Appendix A. SECTION VIl: EQUIPMENT, SUPPLIES AND LEARNING RESOURCES 20. Will sufficient equipment be available to meet the curriculum objectives established by the Executive Director? Yes No Comment(s): 21. Will sufficient equipment be available to accommodate the number of students enrolled? Yes No Comment(s): 22. Will any equipment be borrowed? Yes No Comment(s): If yes, submit a list of equipment provided through written agreement to the fire training program to meet the curriculum established by the Executive Director under Appendix A. 23. Does the library / media center include current fire periodicals, training books, audio-visuals, self-instructional resources, and other references? Yes No Comment(s): 24. Describe the type of informational resources that will be available to students and faculty. EMS /15 [ ] Page 7 of 25 SECTION VIII: CURRICULUM 25. Will the fire training program comply with the Ohio curriculum by including topics in all areas approved by the Executive Director? Yes No 26. How will the training program ensure that curriculum requirements are being met by program instructors? Check all that apply. Course Syllabus Lesson Plans Student Workbooks Classroom Observation Written Examination Student Course Evaluation Practical Skills Assessments Student Assignments Other

8 SECTION IX: EVALUATION 27. Describe how the training program will use the course objective check-off and practical skill evaluation sheets provided by the Division of EMS. 28. Describe how the practical skills component of the curriculum will be integrated into the initial training course; include the student / instructor ratio for practice sessions. 29. What methods will be used by the training program to evaluate the effectiveness of the course and the teaching and learning strategies? Students Course Evaluation Written Quiz / Exam Results Instructor Feedback State Written Examination Results State Practical Skills Exam Results Advisory Board Feedback Practical Skill Evaluators Feedback Course Objective Check-Off Sheets Other 30. Please indicate the type of documentation to be maintained in the course files. Check all that apply. Course Syllabus Course Schedule Lesson Plans Attendance Records Copies of Quizzes / Tests Skill Sheets / Checklists Grade Book Objective Check-Offs Electronic Grading Printout Students Course Evaluations Accident and Injury Reports Live Fire Training Documents Instructor Evaluations Skills Coordinator Evaluations Course I.D. Numbers SECTION X: STUDENT SERVICES 31. Explain how the training program admission requirements meet those to obtain a certificate of fire training in accordance with clearly defined and published practices of the institution and consistent with R.C and O.A.C , , and Describe the training program written policy prohibiting discrimination in acceptance of students on the basis of age, race, color, religion, gender, sexual orientation, or national origin. 33. Describe how the training program will ensure all students entering into the fire training course are State certified at the pre-requisite level on the first day of the course. 34. Explain how the fire training program will ensure that students are not operating as a member of a response crew during class time. EMS /15 [ ] Page 8 of 25

9 SECTION XI: FAIR PRACTICES 35. A written policy must be available to students identifying all of the following requirements: Admission requirements Prohibition against discrimination towards students Refunds of tuition payments Criteria for successful completion of each training course Costs associated with the training program including tuition, materials, and fees Methods for determining grades Information regarding schedule, content, and objectives Criteria for successful completion of each component of curriculum Attendance requirements and procedures to make-up work for missed course hours Grounds for dismissal from the course Disciplinary and grievance procedures including mechanism for appeals Policies and procedures for voluntary student withdrawal from the course Requirements or restrictions regarding student attire or appearance Prohibition against assigning students to emergency response duties during scheduled training hours Procedures for reporting accidents and injuries sustained during a course Procedures for conducting live fire training evolutions that meet NFPA 1403, Standard on Live Fire Training Evolutions Submit documentation of required written policies under Appendix D. 36. A written policy shall also be made available to fire instructor and fire safety inspector instructor students identifying the following requirements, when conducting online and / or distance education courses in accordance with O.A.C : Admission requirements Minimum requirements for technological needs for the student to participate in online and / or distance education courses Technology support to students enrolled in online and distance education courses Security parameters protecting students financial and personal information Procedures for administration of online and / or distance education courses Procedures identifying how the student will have weekly access to the instructor Method to transition from online or distance education course into a traditional classroom course Submit documentation of required written policies under Appendix D. SECTION XII: EXAMINATION PRACTICES 37. Describe how the chartered program meets all requirements for administration of the practical skills examinations and written examinations in accordance with O.A.C and , to include the following: Ensures the integrity and security of all practical and written examinations Ensures a current signed Written Testing Agreement with the Executive Director is on file with the Division of EMS Ensures each proctor has received directions in the state examination process and is familiar with all registration, security, and access procedures for testing Ensures that only qualified candidates sit for the examinations Ensures that the program director, or their designated proctor, shall be present in the examination room for the duration of the examination EMS /15 [ ] Page 9 of 25

10 Ensures that no firefighter, instructor, or EMS instructor shall proctor or be present during the examination unless the individual is sitting for the examination as part of the course requirements Ensures no unauthorized electronic devices including, but not limited to: personal laptops, cell phones, flash drives, and tablets shall be permitted in the examination room or used during the examination process Ensures the responsibility for the administration and set up of the practical skills examination Ensures the practical skill stations are set up prior to the scheduled examination time Ensures the program director or a designated skills coordinator supervises the practical examinations Ensures that appropriately certified and trained instructors conduct the evaluations during practical skill examinations Ensures that the lead instructors are not permitted to evaluate any of their students Ensures the safety of students by providing equipment, supplies, and apparatus that meets NFPA 1001, Standard for Fire Fighter Professional Qualifications performance objectives for all practical examinations Ensures candidates are not permitted to directly observe other candidates during the practical skills examination Ensures that any potential compromise of the practical or written examination process is immediately reported to the Executive Director 38. Describe how the fire charter program ensures that eligible students receive adequate notice of all practical and written examinations. 39. Describe the procedures and processes followed by the chartered program to maintain the examination and testing records for all students. 40. Describe the chartered program s record retention policy for maintenance of student training records. 41. What are the chartered program s policies regarding notifying candidates of their written test scores, including notification method, timeliness, and who may receive the scores? 42. Describe how the chartered program ensures that the facilities and equipment at the test locations are adequate for completion of the job performance requirements, requisite knowledge, requisite skills, and objectives to be tested. 43. Describe the chartered program s policies for ensuring that there is adequate space between persons taking written and / or web-based course and certification exams. 44. Explain the chartered program s policy that establishes the minimum requirements for equipment and apparatus to be safely utilized for practical skills testing, and when required, have equipment and facilities to adequately test all live fire training requirements. 45. Describe how the chartered program will ensure that adequate supervision is provided to maintain security and safety during practical and written certification tests. 46. Describe the chartered program s policies regarding persons leaving the supervised testing area during the practical and written certification exams. EMS /15 [ ] Page 10 of 25

11 47. Describe the chartered program s policy to ensure that qualified persons are chosen to proctor the written and / or web-based knowledge exams and what training each have received in the course management and state examination process. 48. Describe the charter program s policy on training persons utilized as practical skills evaluators. The agency must have a procedure in place to qualify individuals who administer or evaluate knowledge, skills, or abilities in accordance with rule of the O.A.C. 49. Explain how practical skills evaluators receive instructions regarding the evaluation process. 50. Describe how the charter ensures that the persons used as evaluators have not been the instructor for the specific training of the candidate in the skills being examined or evaluated. The agency must have a policy in place that prohibits an instructor from teaching and evaluating the same skills. SECTION XIII: LIVE FIRE TRAINING 51. Describe the procedures that the charter program will utilize to ensure NFPA standard 1403, Standard for Live Fire Training Evolutions, will be used. Documentation must be provided, including a diagram of the burn building / facility. Submit documentation of required written policies, including diagrams, under Appendix D. 52. Describe how the charter program will document that a fire instructor or assistant fire instructor utilized in instruction of any live fire evolution has completed the Live Fire Training Operations Course In accordance with O.A.C (For new instructors after April 7, 2014) 53. Does the charter program have a live burn structure at your facility? Yes No If so, please describe the type of facility (i.e., fixed gas-fired, fixed non-gas-fired, containers, mobile lab, etc.) 54. Do you have an affiliation agreement with another institution that does have a live burn structure? Yes No If so, please describe the type of facility (i.e., fixed gas-fired, fixed non-gas-fired, containers, mobile lab, etc.) SECTION XIV: FIRE ADVISORY COMMITTEE 55. The charter program shall provide a listing of their advisory committee; include names, positions, fire department affiliation and / or organization, mailing addresses, addresses, and business phone numbers. Submit documentation of advisory committee under Appendix A. 56. Explain how charter will ensure proper documentation of advisory committee meeting minutes to include the agenda, discussion of issues, and the attendance record for each meeting that is conducted in accordance with O.A.C Explain how all affected associations and organizations within the charter program s jurisdiction are represented by the advisory committee. If not represented, describe how all affected groups within the charter program s jurisdiction have access to the agency in such a way that their views, opinions and desires may be expressed and receive fair consideration. EMS /15 [ ] Page 11 of 25

12 I attest that all information included in this application is true and accurate to the best of my knowledge. I understand a false statement on this application could constitute falsification under Section of the R.C. and is a misdemeanor of the first degree. Any false statement may be grounds for denial, suspension, revocation or other disciplinary action taken against this charter or classification level. As the Authorizing Official, I recognize that I am responsible for ensuring that all laws and rules pertaining to this charter (including any duties delegated to the Program Director) are followed. I agree to provide a copy of this application to the Program Director listed on this application, as well as, any new Program Director who may be assigned during this charter period. I understand I must maintain records relating to the charter requirements and such records are subject to audit by the Division of EMS. I hereby give permission to the Ohio Department of Public Safety, Division of EMS to verify any of the information contained herein. OF AUTHORIZING OFFICIAL (PRINTED) SIGNATURE OF AUTHORIZING OFFICIAL X DATE READ AND RECEIVED OF PROGRAM DIRECTOR (PRINTED) SIGNATURE OF PROGRAM DIRECTOR X DATE EMS /15 [ ] Page 12 of 25

13 APPENDIX A In order for a Fire Charter Application to be deemed complete and to be considered by the Executive Director, all of the documentation listed on this page shall be submitted to the Division of EMS with the application. Where provided, please use the templates in completing your application. Appendix A Authorizing Official statement of support for the fire charter Charter training program organizational chart Advisory Committee membership list Demonstration of adequate financial resources to operate the fire charter Current and signed affiliation agreements for equipment, supplies, facilities, and apparatus List of current approved fire training offsite locations EMS /15 [ ] Page 13 of 25

14 FIRE CHARTER ADVISORY COMMITTEE MEMBERSHIP In accordance with O.A.C , the Advisory Committee shall include a minimum of five people, to include the program director, fire chiefs, instructors and others from the fire community. (Copy page, if additional space is needed) POSITION ADDRESS AFFILIATION ADDRESS BUSINESS TELEPHONE NUMBER CERTIFICATION LEVEL Firefighter FSI Fire Inst. FSI Inst. Other POSITION ADDRESS AFFILIATION ADDRESS BUSINESS TELEPHONE NUMBER CERTIFICATION LEVEL Firefighter FSI Fire Inst. FSI Inst. Other POSITION ADDRESS AFFILIATION ADDRESS BUSINESS TELEPHONE NUMBER CERTIFICATION LEVEL Firefighter FSI Fire Inst. FSI Inst. Other POSITION ADDRESS AFFILIATION ADDRESS BUSINESS TELEPHONE NUMBER CERTIFICATION LEVEL Firefighter FSI Fire Inst. FSI Inst. Other POSITION ADDRESS AFFILIATION ADDRESS BUSINESS TELEPHONE NUMBER CERTIFICATION LEVEL Firefighter FSI Fire Inst. FSI Inst. Other POSITION ADDRESS AFFILIATION ADDRESS BUSINESS TELEPHONE NUMBER CERTIFICATION LEVEL Firefighter FSI Fire Inst. FSI Inst. Other EMS /15 [ ] Page 14 of 25

15 SITE APPROVED FIRE TRAINING OFFSITE LOCATIONS List all sites to be used for course offerings (Copy page, if additional space is needed) SITE SITE SITE SITE SITE SITE SITE SITE SITE SITE SITE SITE SITE SITE SITE SITE SITE EMS /15 [ ] Page 15 of 25

16 APPENDIX B In order for a Fire Charter Application to be deemed complete and to be considered by the Executive Director, all of the documentation listed on this page shall be submitted to the Division of EMS with the application. Where provided, please use the templates in completing your application. Appendix B List of s, Assistant s and Fire Safety Inspector Instructors utilized by charter, including certification numbers and expiration dates Copy of all evaluation forms from instructor supervisors / peers List of name(s) of the charter proctor(s) for the state certification examination List of instructors utilized as skill coordinators and evaluators for the practical skills testing. Include the date of completion of the Practical Skills Evaluator Training Course in addition to their certification numbers, certification levels, area(s) of expertise, and expiration dates List of instructors utilized in any live fire training evolutions. Include the date of completion of the Live Fire Training Operations Course (For new instructors after April 7, 2014) EMS /15 [ ] Page 16 of 25

17 INSTRUCTOR ROSTER List the instructors that will be utilized by the charter program. (Copy page, if additional space is needed) Has the program director verified all the instructors utilized have a current and valid Ohio certificate to practice and certificate to teach that are not under disciplinary action by the Executive Director? Yes No Asst. Asst. Fire Safety Inspector Instructor Fire Safety Inspector Instructor Asst. Asst. Fire Safety Inspector Instructor Fire Safety Inspector Instructor Asst. Asst. Fire Safety Inspector Instructor Fire Safety Inspector Instructor Asst. Asst. Fire Safety Inspector Instructor Fire Safety Inspector Instructor Asst. Asst. Fire Safety Inspector Instructor Fire Safety Inspector Instructor EMS /15 [ ] Page 17 of 25

18 INSTRUCTOR TRAINERS List the instructor trainers that will be utilized by the charter program. (Copy page, if additional space is needed) Has the program director verified all the instructor trainers utilized have current and valid Ohio certificates to practice and certificates to teach that are not under disciplinary action by the Yes No Executive Director? Has the program director verified the instructor trainer meets the requirements of O.A.C ? Yes No Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer Trainer FSI Instructor Trainer EMS /15 [ ] Page 18 of 25

19 FIRE CHARTER PROCTORS FOR WRITTEN CERTIFICATION EXAM List the proctors that will be utilized by the charter program. (Copy page, if additional space is needed) CITY, STATE, ZIP CITY, STATE, ZIP TELEPHONE NUMBER TELEPHONE NUMBER CITY, STATE, ZIP CITY, STATE, ZIP TELEPHONE NUMBER TELEPHONE NUMBER CITY, STATE, ZIP CITY, STATE, ZIP TELEPHONE NUMBER TELEPHONE NUMBER CITY, STATE, ZIP CITY, STATE, ZIP TELEPHONE NUMBER TELEPHONE NUMBER CITY, STATE, ZIP CITY, STATE, ZIP TELEPHONE NUMBER TELEPHONE NUMBER EMS /15 [ ] Page 19 of 25

20 SKILL COORDINATOR / EVALUATOR ROSTER List the skill coordinators / evaluators that will be utilized by the charter program. (Copy page, if additional space is needed) Has the program director verified all instructors utilized have current and valid Ohio certificates to practice and certificates to teach that are not under disciplinary action by the Executive Director? Has the program director verified each instructor has taken the Practical Skills Evaluator Course? Yes Yes No No Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE PRACTICAL SKILLS EVALUATOR TRAINING COURSE COMPLETION DATE EMS /15 [ ] Page 20 of 25

21 LIVE FIRE INSTRUCTOR ROSTER List the live fire instructors that will be utilized by the charter program. (Copy page, if additional space is needed) Has the program director verified all instructors utilized have current and valid Ohio certificates to practice and certificates to teach that are not under disciplinary action by the Executive Director? Has the program director verified each instructor has taken the Live Fire Training Operations Course? (For new instructors after April 7, 2014) Yes Yes No No Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE Asst. Fire Inst. Fire Inst. FSI Inst. Asst. Fire Inst. Fire Inst. FSI Inst. LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE LIVE FIRE OPERATIONS TRAINING COURSE COMPLETION DATE EMS /15 [ ] Page 21 of 25

22 APPENDIX C In order for a Fire Charter Application to be deemed complete and to be considered by the Executive Director, all of the documentation listed on this page shall be submitted to the Division of EMS with the application. Where provided, please use the templates in completing your application. Appendix C Student admission application Copy of proposed syllabus for each fire training level to be offered Curriculum hours for each classification level to be offered Course schedule and lesson plans for each fire training level to be offered Fire testing and practical skills forms and documentation Copy of students course evaluation form Online or distance learning documentation EMS /15 [ ] Page 22 of 25

23 Volunteer Firefighter Curriculum FIREFIGHTER AND FIRE SAFETY INSPECTOR CURRICULUM HOURS TOPIC Enter the number of hours devoted to each topic by your program curriculum. RECOMMENDED TRAINING HOURS Fire Department Organization and Safety 3 Fire Behavior 1 Overhaul 1 PPE / SCBA 6 Fire Hose, Appliances, and Streams 3 Fire Control 2 Rescue 2 Water Supplies 3 Forcible Entry 2 Ventilation and Tools 3 Fire Extinguisher 1 Ground Ladders 3 Practical Evolutions 6 Total Course Hours 36 Hours maximum PROGRAM TRAINING HOURS Firefighter I Curriculum TOPIC Enter the number of hours devoted to each topic by your program curriculum. RECOMMENDED TRAINING HOURS Fire Department Organization and Safety 3 Life Safety Initiatives 4 Fire Alarm and Communication 2 Fire Behavior 3 Overhaul 1 PPE / SCBA 6 Fire Hose, Appliances, and Streams 9 Fire Control 16 Fire Cause and Origin 1 Rescue 2 Water Supplies 3 Fire Detection Alarm and Suppression Systems 2 Fire Prevention, Fire Education, and Fire Cause 2 Building Construction 8 Forcible Entry 6 Ventilation and Tools 12 Ropes 3 Salvage 4 Fire Extinguisher 3 Ground Ladders 11 Emergency Medical Services 8 Hazardous Material 16 ICS 1 Live Fire Training 8 Emergency Vehicle Operation Course 16 Practical Evolutions 6 Total Course Hours 156 Hours minimum PROGRAM TRAINING HOURS EMS /15 [ ] Page 23 of 25

24 Firefighter I & II Curriculum TOPIC Enter the number of hours devoted to each topic by your program curriculum. RECOMMENDED TRAINING HOURS Fire Department Organization and Safety 8 Life Safety Initiatives 4 Fire Alarm and Communication 6 Fire Behavior 3 Overhaul 1 PPE / SCBA 6 Fire Hose, Appliances, and Streams 16 Foam Fire Control 13 Fire Control 23 Fire Cause and Origin 6 Rescue 32 Water Supplies 7 Fire Detection Alarm and Suppression Systems 12 Fire Prevention, Fire Education, and Fire Cause 6 Building Construction 13 Forcible Entry 6 Ventilation and Tools 12 Ropes 3 Salvage 4 Fire Extinguisher 3 Ground Ladders 11 Emergency Medical Services 8 Hazardous Material 16 ICS 1 Live Fire Training 18 Emergency Vehicle Operation Course 16 Practical Evolutions 6 Total Course Hours 260 Hours minimum PROGRAM TRAINING HOURS Fire Safety Inspector Curriculum TOPIC Enter the number of hours devoted to each topic by your program curriculum. RECOMMENDED TRAINING HOURS Administration 12 Plan Review 1 Complaints 3 Code Compliance 13 Egress 6 Occupancy Load 3 Protection Systems 16 Construction Type 2 Hazardous Materials 9 Fire Growth 6 Water Supply 1 Total Course Hours 72 Hours minimum PROGRAM TRAINING HOURS and Fire Safety Inspector Instructor Curriculum Please refer to the Ohio Fire and EMS Instructor Curriculum located on the Division of EMS Web site ( regarding and Fire Safety Inspector Instructor curriculum requirements. EMS /15 [ ] Page 24 of 25

25 APPENDIX D In order for a Fire Charter Application to be deemed complete and to be considered by the Executive Director, all of the documentation listed on this page shall be submitted to the Division of EMS with the application. Where provided, please use the templates in completing your application. Appendix D Written policies and procedures in compliance with O.A.C Written policies and procedures for conducting live fire training (includes live fire burn plan and diagram of burn facilities) Written policies and procedures for the administration of the state practical skills and written examinations Policies and procedures for management of student, course, and instructor records Original copy of current signed Written Testing Agreement EMS /15 [ ] Page 25 of 25